Critics say the criteria are too vague and could lead to veterans feeling they were unfairly denied access to Community Care. For instance, drive time depends on the time of the day when it’s calculated.
“I’ll be on the borderline of qualifying for Community Care, and they’ll probably turn me down,” fretted Navy veteran Ray Rubio, who lives in Chicago’s south suburbs and prefers private-sector care because he’s been dissatisfied with the VA care he’s received.
The Disabled Veterans of America wants new access standards tested before the program launches.
The access standards for Community Care would significantly increase the number of VA enrollees using VA-paid healthcare rather than the other health insurance most veterans have, such as Medicare or an employer plan, according to a Milliman analysis. Enrollees’ reliance on VA-paid care would rise from 36% to 40% by 2021, with the VA spending an estimated $18.7 billion more over five years.
The U.S. Digital Service reported in March that the proposed drive-time standards would hike the number of veterans eligible for community-based care from 685,000 under the Veterans Choice program to 3.7 million.
It warned, however, that flaws in the digital support tool the VA is developing to determine eligibility would slow appointments and lead to VA physicians seeing 75,000 fewer patients a day, causing major disruptions. Wilkie denied that claim.
The sharp increase in the number of veterans eligible for community-based care has raised alarms among lawmakers and VA supporters about whether higher spending will squeeze funding for the VA system. Congress did not appropriate additional money for the new program, though the VA says it has sufficient funding for 2019.
“These increased costs for Community Care will likely come at the expense of the VA’s direct system of care,” a group of Democratic senators led by Montana Sen. Jon Tester warned in January.
Kayla Williams, director of the veterans program at the nonpartisan Center for a New American Security, shares that concern. An Army veteran who served in Iraq, Williams said she’s received both VA care and private-sector care through the military’s TriCare insurance plan, and that her care in the VA system was better coordinated and more comprehensive.
“I don’t completely oppose this new Community Care program because bringing all these programs into one system makes more sense,” she said. But expansion of care in the community “should not come at the expense of a strong VA.”
She and other experts say private-sector providers generally can’t match the VA’s 172 hospitals and 1,069 outpatient clinics in delivering care that’s attuned to military culture and the unique medical needs of veterans, who tend to be sicker on average than non-veterans. Those special needs include toxic exposures, spinal cord injuries, prosthetics for lost limbs, and post-traumatic stress disorder, with which many community providers have little or no familiarity.
Williams said three female veterans she knows were diagnosed with breast cancer in their 30s because VA providers were aware of their exposure to toxins and ordered mammograms at a younger age than is typically recommended. “There’s nothing that shows civilian providers would know what to screen for,” she said.
The VA has not yet said how it will ensure that non-VA providers are culturally competent to serve veterans and able to provide the range of services veterans need. Up to now, there has been no systematic analysis of the timeliness or quality of care that veterans receive through VA community programs, according to the RAND Corp.
Indeed, a RAND survey last year of hundreds of private-sector providers in New York state to assess their readiness for treating veterans with service-connected health issues found that only 2.3% met a number of key readiness criteria. Those included familiarity with military culture, preparedness to screen for and treat conditions common among veterans, and accommodation for patients with disabilities.
Nearly 60% of the New York providers said they did not want additional training for working with veterans.
“The number of providers who met our full criteria for readiness was much lower than we anticipated or that is desired,” said Terri Tanielian, a senior behavioral scientist at RAND who worked on the New York study. “Our findings support concerns about the uneven level of quality between VA and community providers.”
There are health systems, however, that have developed close working relationships with VA facilities and whose providers have gained substantial experience in serving veterans since the Choice program started in 2014.
One is Northwell Health, which built a clinic to serve veterans and their family members in collaboration with the Northport (N.Y.) VA Medical Center. On one side, VA providers serve the veterans, while on the other side Northwell providers serve the family members.
Even with the experience of serving thousands of military families, it’s no small task for Northwell to train its clinicians in the unique needs of veterans and get ready for a possible increase in patients under the expanded community program.
That means helping clinicians understand the different physical and behavioral conditions veterans may present with, how to accommodate patients with disabilities, and the availability of special programs and resources for veterans, said Dr. Tochi Iroku-Malize, Northwell’s family medicine chair.
Given clinicians’ busy schedules, she plans to use online training modules and clinical rounds focusing on veterans’ needs. “The case of the day may be a veteran with PTSD and what’s causing his heart rate to go up so fast,” she said. “I have to make sure my clinical workforce is prepared for this.”
Former VA Secretary Shulkin said Congress must be ready to jump in fast if problems with the new Community Care program arise after its launch.
“This is an aggressive time schedule, but that isn’t a problem,” he said. “You have to be really committed to monitoring the impact of this very closely, and be open and transparent. No one wants to see a well-intended policy result in disaster.”
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